Tackling the high prevalence of type two diabetes among South Asian adult population (30-60) in London borough of Croydon.

Contents page

Chapter 1:                Title Page……………………………………………………………….  1

Chapter 2:                Contents page…………………………………………………………. 2

Chapter 3:                 Introduction……………………………………………………………. 3

Definition of Diabetes………………………………………………….4

Diabetes data in Croydon………………………………………………5

The Aim and the Objectives…………………………………………. 6

Chapter 4:                 Identified need: Epidemiological data and demographics ……………. 7

Health inequalities and social determinants of health ………………………7

Chapter 5:                Evidence: Local Policies and Service Provision………………………..11

Effective Interventions………………………… ……………………13

     Chapter 6:             Intervention Plan…………………………………………………….19

Ethics……………………………………………………………….19

Stakeholder Analysis………………………… …………………….19

Budget/Resources……………………………………… ……………21

Chapter 7:                 Conclusion/ expected outcome………………………………………22

Chapter 8:                  References………………………………………………………….23

Chapter 3

INTRODUCTION

This research project will comprise of an intervention plan to improve health and it will be focusing on tackling the high prevalence of type 2 diabetes(T2D) among South Asian Adults (30-60) in the London borough of Croydon. It will equally seek to analyse the rational for the topic, target group demographics, statistics and the epidemiological information for Croydon. Furthermore, it will be discussing the health inequalities, morbidity, mortality rate and the social determinants of health in relation to tackling to the high prevalence of T2D. Also, the evidence of Croydon local policies and strategies geared at tackling T2D will be examined. Moreover, a clear justification and description of the methodology, ethical consideration and measures involved in developing the intervention will be discussed. This will be followed by highlighting on expected outcomes and the conclusion. Finally, the layout for this research will be presented in chapters and will relate to the contents page for specific page numbers.

In todays, world, modernisation and technological advancements have brought a lot of changes in human behaviour and lifestyle. Although this changes have improved our lives and health in many ways but on the other hand, it has resulted to a high increase on the incidence of diabetes worldwide. The main epidemic of this metabolic diseases is the T2D which is associated with ethnicity, environmental and behavioural factors (Zimmet et al.,2001). Additionally, researches has equally confirmed the global epidemic of this disease and its complication. T2D is presently a public health burden with approximately 422 million people affected by the condition universally and the trend is expected to be more than double in the next 20 years WHO (World Health Organisation,2016). Besides, UK and England are not an exception of this trend as they have experienced an upswing in the prevalence of T2D.The recent figure for people living with diabetes in UK has reached its peak with over 4 million people with the condition, this figure includes 3.5 million adults who are diagnosed with this condition while 549,000 people are yet to be diagnosed (Diabetes UK,2016). In England, about 3.8 million people are estimated to have both Type 1 diabetes and Type 2 diabetes however, approximately 90% of diabetes cases are Type 2 PHE, (Public Health England, 2016). In addition to this, Diabetes.co.uk, (2017), Diabetes UK, (2016) and Yoon et al., (2006) concludes that the prevalence of T2D is 6 times higher in South Asian descent than in general populations. They also have an early onset of this condition from the age of 25 as opposed to age 40 onsets in White population. Therefore, National Institute for Health and Clinical Excellence, (2013) NICE, recommends a lower BMI (Body Mass Index) of 23 kg/m2 and 27.5 kg/m2 to indicate high risk of developing T2D in South Asians and 25 kg/m2 and 30 kg/m2 in White Europeans.

According to Bhurji et al., (2016), South Asians are people from Pakistan, Bangladesh or India and they encounter up to 50% higher risk of developing type 2 diabetes compared with the rest of the population regardless of whether they live in South Asia or in Western countries. People from South Asian descent make up nearly 4% of UK population but account for approximately 8% of most diagnosed cases of diabetes(Diabetes.co.uk,2017). The burden and increased risk of developing this condition in South Asian origin is linked to many factors of which genetics and life style factor are inclusive of them(Diabetes.co.uk,2017). In response to this, Yoon et al, (2006) clearly states that urgent intervention is required to tackle this problem. Hence, South Asian are important target group to be considered when plaining an intervention to tackle the high prevalence of T2D universally.

Definition of diabetes

Diabetes is progressive, serious and chronic disease which occurs when the pancreas has failed to produce enough insulin or the insulin produced cannot be properly utilised. This leads to an elevated concentration of the glucose present in the body hence, leading to some serious complications if not properly managed(WHO,2016).

The two major types of diabetes are:

• Type 1 diabetes
• Type 2 diabetes.

Type 1 diabetes which also previously known as insulin-dependent, juvenile or childhood-onset is a type of diabetes which occurs when the insulin producing cells (beta cells) in the pancreas have been destroyed resulting to the inability of the body to produce insulin to regulate the blood glucose levels adequately. This condition requires regular administration of insulin(Diabetes.co.uk,2017).

Type 2 diabetes develops when the pancreatic cells do not produce enough insulin or there is resistance in the insulin produced in the body (Diabetes UK,2016).

Type 2 diabetes was formally known as non-insulin dependent or adult-onset type of diabetes because it used to be more common in people over the age of 40.However this is not the case these days as the onset of type 2 diabetes in becoming more common in young adults, teenagers and children, accounting for about  90% of  diabetic cases around the globe (Diabetes UK,2016).It can occur because of certain factors such as physically inactivity, genetics, unhealthy diet, obesity, alcohol consumption and ethnicity. (WHO,2016).

Diabetes data in Croydon

Diabetes is considerable a health issue in Croydon, JHWS(2013/18) and Annual Public Health Profile, (2015) have shown that the prevalence of diabetes has been on a steady increase in Croydon and around 1 in 13 people has diabetes in Croydon. The estimated prevalence of diabetes in 2009 was at 5%, towards the end of March 2010, the number increased to nearly 16,516. Also, just over one in 23 of all patients registered with their General Practitioner (GP) in Croydon had a diagnosis of diabetes and it is reckoned that more 2,666 patients registered with Croydon Gps do not have a correct diabetes records or have not been diagnosed. In 2015, the total number of people diagnosed with diabetes climbed to over 19,900 while additional 6,400 are not aware they have it. Furthermore, the rate of diabetes in Croydon was at a staggering 6.6%(20,406) local no of total count and 9.2% worse than England average between 2014/2015.This is significantly high compared to the rate in other boroughs like Sutton and Bromley with just under 6.1% 5.4% respectively (PHE, 2016). In terms of prevalence rates among people from different ethnicities in Croydon, South Asians (Bangladeshis) have been identified to have the highest prevalence rate of about 14% while people from White Irish Decent had the least with just under 2.9% (Annual public health profile, 2015). Moreover, the rate of diabetes amongst men is higher compared to that of women of all ages and rate of obesity in people who are diagnosed with diabetes is twice as those in the general population. However, the prevalence of diabetes is highest in the west Thornton area with over 7.6% due to the high population of South Asians living in this area (Croydon JSNA,2010/2011). In addition, diabetes is also one of the causes of high mortality rate in Croydon residents aged 22 and 79 and have caused nearly 14% deaths among residents in this age bracket. Each year, about 306 people die from this condition and almost 38% of major amputation cases in diabetic patients (JHWS 2013/18) and (Annual public health profile, 2015).

AIMS

To reduce the high prevalence of type two diabetes by promoting healthy eating and physical activity among South Asian adults in London Borough of Croydon.

OBJECTIVES

• To increase the awareness and knowledge of consuming healthy diets among target group through professional information and advice by a dietitian during community workshop.

• To provide an opportunity for community nurses to offer NHS health checks and weighing in other to identify individuals that are at high risk of developing T2D and delivering one to one support to them during work shop.

• To encourage physical activity through advice and support by a trained exercise instructor and support individuals to develop a goal plan if they wish to do so.

• To analyse some behaviours and food habits that contribute to unhealthy eating and discussing how to reduce or prevent them through group discussion.

Chapter 4

IDENTIFIED NEED: DEMOGRAPHY AND EPIDEMIOLOGICAL DATA.

London borough of Croydon is a very diverse and densely populated borough with approximately 380,700 people living in it, making Croydon one of the biggest borough in London and the population is estimated to reach 465,600 by 2041. Croydon has a younger population profile than England and older than London. The population is higher in the number of children aged under of 5 and a larger number of people aged 45-64. It has also been recorded that Croydon has the 5th highest number of children aged 0 to 19 (26.9%) out of any London borough compared with London (24.5%) and England (24.0%) JHWS (Joint health and wellbeing strategy, 2013‐2018).

JHWS (2013-2018) also indicates that migration is one of the significant changes in Croydon’s population and the number of people from different ethnicities moving into this borough has been on steady increase. Croydon experience over 6,000-7,000 new immigrants from outside the UK per year. Besides the population of South Asians moving into the borough have been higher when compared to the number of people from other ethnicities. A total number of 2,300 people from (India, Pakistan and Sri Lanka) migrate to Croydon each year while nearly 1,100 people from Eastern Europe and only 500 immigrants from Ghana and Nigeria. Thus around 100 different languages are spoken by Croydon communities.

Despite the increase in migration, differences in ethnicities the social determinants of health, and other factors, life is generally good for most people living in Croydon. Nevertheless, some differences exist in the health of people living in Croydon when compared to England average. The health of adult population in smoking related deaths, hospital stay due to self-harm and alcohol related hospital stay is better than England average rate while the figure for obesity in adult is same with England average at the rate of 24.3%. On the other hand, the rate of tuberculosis and sexual transmitted infections (STIs) is worse than England average (PHE,2016).

Health inequalities.

According Marmot Review, (2010), Health equalities are consequences of social inequality and links to the social gradient in health which means “the lower peoples position are, the worse their health will be”. Health inequality is one of the most important factors that have been persistent and difficult to change. Maclnytre, (2011) states that the health inequality is widening in Croydon and will continue to do so if not properly tackled. Consequently, this affects peoples’ ability to access health care services such as Croydon diabetic services and people living in deprived areas have less access to such services. Croydon JSNA, (2009-2010) concludes that geographical health inequalities still exist in the borough and is the leading cause of inequality gap in provision of services. The life expectancy for people living in Croydon is rising faster for men than for women living in the borough. Nevertheless, some little gap is still present in the life expectancy gap between the most deprived wards and least deprived wards in Croydon. Males are expected to live 9.4 years lower and 7.6 years lower for women in more deprived areas of Croydon. However, life expectancy for both areas are more than England average. This also affects the life expectancy gap between the most deprived and the least deprived, resulting to the differences in preventable deaths between the deprived and least deprived. Additionally, records have shown that Croydon has the second highest inequality gap in London for premature deaths resulting from cardiovascular diseases, cancer and stroke. These disease conditions are also the overall causes of mortality and morbidity in Croydon (PHE,2016) and (JHWS,2013-2018). Furthermore, JSNA, (2009-2010) indicates that the prevalence health inequality in Croydon is better than the national average based on number health inequalities shown by the Marmot, (2010) review. This means that Croydon is doing their best to tackle inequality using the six policy goals of Marmot Review, (2010).

The main social determinants of health associated with T2D are as follows

• Deprivation
• Poverty
• Obesity

Deprivation is another key determinant of T2D and is associated to several factors such as low income, poor housing, unemployment, unhealthy eating, physical inactivity, obesity and low educational attainment. Deprivation in Croydon has continuously been on the increase due to increase migration and high birth rate but it is still considerably better than England average at 17.3% compared to 20.4% England value (PHE,2016). Croydon is currently the 19^th deprived borough in South area of London and by 2020, it is predicted to be the 12^th most deprived borough in London (JHWS,2013‐2018).

Findings from Maclntyre, (2011) shows that the prevalence rate of diabetes is highly associated with deprivation and is up to 70% greater for people living in the most deprived areas of the borough than those in the least deprived areas. Also, Gatineau et al, (2014) also suggests that T2D is 40% more popular among people living in deprived areas in England compared with those in least deprived areas.People that are of low class (unskilled manual) are up to three and a half times very likely to suffer from illnesses due complications from diabetes than those in upper class (professionals)^. Therefore, the short-term mortality risk due to T2D is more significant among those living in more deprived areas in England.  Similarly, this is the case of deprivation in Croydon and some data have shown that increased levels of deprivation is associated with poor health and wellbeing outcomes which increases the mortality rate to three times higher in the most deprived wards in Croydon than in the least deprived wards (JSNA,2012).

Poverty and inequality has greatly determined the health status of people in London and in Croydon borough. Data from London Voluntary and Community Action London, (2010) shows that about 40% of BME Londoners live in poverty and low income compared to 20% of White Londoners. Moreover, some people from South Asian backgrounds (Bangladeshi) still live in unacceptable low income households than other ethnicities. Similarly, report from Croydon JSNA, (2012) shows that almost 22%(16,900) of children are from low income families. Besides the poverty rate in children under the age of 16 is apparently worse than England average at (21.8%)this is more than doubled when compared to rate in Croydon Neighbouring town Bromley with only (14.9%). Child poverty affects children negatively and have a long-lasting effect on so many aspects of an individual’s life. Children who live in poverty or are brought up in poverty are more likely to achieve a lower level of educational attainment than their counterpart from well-off backgrounds. They are also more likely to grow into unhealthy adults which makes them more susceptible to T2D and other diseases. The rate of infant mortality is equally high and Croydon is in the worst 10% local authorities for low birth weight in babies which is associated with inequality and poverty.

Obesity is also a social determinant of health and the raise in the incidence of T2D is significantly linked to obesity. Once, more   people living in deprived areas of Croydon are more than twice as likely to be overweight compared to people living in more prosperous areas (Croydon Council,2015). Being overweight makes them more prone to T2D which is often related to their inability to afford healthy diets and lack of access to local services that can increase physical activity. Hence a combination of unhealthy eating and physical inactivity leads to a high BMI of over 25kg and increased waist circumference which are the major modifiable risk factor for onset of type 2 diabetes (Gatineau et al, 2014).

Importantly, some reports have shown that Croydon is doing their best in tackling the social determinants of health and have developed some strategies to improve the health and social wellbeing of their community members. The (JHWS,2013‐2018)   have set out some policies and priorities to reduce the rate of inequalities, deprivation, obesity, diabetes and high infant mortality rate (Croydon Council 2016).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chapter 5

 

 Evidence of Local Policies and Service Provision

Despite the international, national and local polices geared preventing and managing the high prevalence of T2D, tackling this condition continues to be a challenge universally. Interestingly, Croydon have developed some existing local policies and services that are in line with NICE guidance for the prevention and management of T2D in the community (NICE,2011).

 

The report from Croydon Council, (2011) shows that some of the existing Croydon diabetes service have been effective to an extent. Firstly, the Croydon Community Integrated Diabetes Service and the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) have been one of the most significant evidence for tackling diabetes in Croydon. These services provide structured education programme to individuals with recent diagnosis of diabetes. The provision of these programmes is cost effective in diabetes care management. Besides, they have been effective in boosting the confidence of newly diagnosed patients and encouraging self-management of their disease condition (Health Innovation Network ,2017). In addition, report from (Croydon Council,2011) shows that people have been able to manage their blood glucose level more effectively and the quality of care have also improved since the lunching of this programme. For instance, data compared from 2008-09 and 2009-10 indicates that Croydon ranking in patient glucose control relative to other PCTs (Primary Care Trust) have dramatically improved from 142 out of 152 PCTs to 82^nd place over a period of one year. Despite this improvement, many people from a focus group said they are not aware of such services existing in the borough while others think that such service is not for them rather for professionals. Maclyntre, (2011) confirmed that only a small explicit of work have been done to create awareness on management of T2D in the deprived areas of Croydon where majority of South Asians and most people from BME live. Once more, this shows inequality and some gap in existing diabetes services. Therefore, facilitating these services through community awareness programme will help to ensure that all people that need this services are aware of it and have equal access to it more especially in the deprived areas.

Another report from Croydon Council, (2011) presents the effectiveness of the Croydon Diabetes Network. The provision of this service links professional, diabetic patients, their families and careers together in other to improve diabetes care and health outcome in the borough. They equally conduct diabetes checks in different schools and monitors diabetes care to ensure that it is in line with NICE Guidance, (2011). Moreover, there are evidence of other existing intervention measures that encourages behavioural and life style changes. The evidence of adapting to behavioural and life style changes relates to the social cognitive theory. Bandura, (1998) suggests that when people are not aware of how their habits affects their health, they are less likely to change from their bad habits to learn new habits compared to when they are aware. Lucas et all, (2013) and South Asian Health Foundation (SAHF,2014) concludes that most South Asians find it very difficult to understand how their behaviour, lifestyle, belief and other factors can impose a health risk to their health. This can be associated to their culture or misconceptions regarding ill-health and diseases. Hence, they do not see the need to modify their lifestyles or habits which consequently increases the risk of T2D.

Furthermore, Croydon Council have designed a lot of services and networks to promote physical activity and healthy eating within the borough. A few examples of these are the healthy living hub, food flagship strategy and Eat well Croydon. However, it can be argued that these available services are not meeting the needs of South Asian Adults in tackling the rising figures of T2D (Annual Public Health Report, 2015). However, (SAHF,2014) Suggests that T2D interventions and management targeted at South Asians should be culturally sensitive in other to be effective. On the hand, this is not the case in most intervention for T2D in Croydon. For instance, South Asian females in Croydon are not able to participate in physical activities due to the fear of going contrary to their religious modesty and believe as they are not supposed to be seen without their religious outfit or taking part in the same activities with men. Consequently, using a religious network and providing a service that meets their needs will encourage them to participate actively in physical or leisure activities thereby reducing the risk of T2D. Also, consuming traditional food is part of South Asians culture, however most of their traditional foods are very high in fat, carbohydrates and sugar. This increases the risk of T2D and makes the management more difficult. Therefore, introducing them to food flagship strategy will encourage them to eat healthier and possibly reduce the early onset of this disease (Annual Public Health Report, 2015) and (SAHF,2014).

Furthermore, Croydon is also using a “Healthier You” measure which is national intervention programme that have been lunched to prevent T2D (NHS Croydon Clinical Commissioning group,2017). This intervention is geared at personalised support to reduce the risk of T2D by giving health education on healthy eating, lifestyle modification and getting more physical active through recommended exercise programmes National Health Service (NHS,2016). Additionally, Croydon NHS services also provides free NHS health check for people within the age bracket of (40-74) to help spot early potential risk and signs of developing T2D, stroke and other diseases.

Effective Interventions

NICE, (2012), have developed some evidenced based guide lines and effective interventions that have been tailored at different groups including Gps, community nurses, other health professionals as well as local NHS, and the wider public for the prevention of T2D among adults more especially individuals that have been identified to be at high risk. These guidelines include encouraging physically activity, healthy diet, weight management, risk identification and assessment (NICE,2012).

The use physical activity has been a proven intervention for tackling the high prevalence of T2D. For instance, Diabetic UK, (2017) suggest that physical activity can reduce the risk of T2D by up to 40% and WHO, (2017) states that lack of physical activity is a considerable risk factor to the development of T2D and other noncommunicable diseases. Another study by (Roux,2017) and (Du, H et al.,2017). have found out that adopting to life style changes such as healthy diet including eating fresh fruits reduces T2D risk and its complication by up to 12%. They also agree that good physical activity with the combination of a new drug called liraglutide (Victoza) can lessen the risk T2D by 80% even in people who are at high risk of developing this condition.

Findings from the Care Quality Commission, CQC, (2016) shows that effective interventions include the use of health educational courses and self-management of diabetes care in the community. According to their community review, people who received structured education courses in the community feel that this has improved their confidence and ability to manage their diabetes more effectively. However, this review concludes that people from BME were less aware of this programme and did not benefit from it (CQC,2016). Similarly, a research carried out by Pate et all., (2017) reveals that community interventions involving life style changes that are culturally tailored and provided in a faith -based community setting can successful help in reducing the risk factors of T2D in South Asian Community. This propose that interventions which targets and recognises the cultural, behavioural and faith needs of South Asians is more likely to work in this community.

In addition, Hameed et al., (2011) and West et al., (2016) supports that a behavioural modification that includes good dietary changes combined with increased physical activity can produce significant weight loss as well as reducing the early onset of T2D more especially in obese people and high risk group. This intervention is also proven to be cost effective and equally reduces the risk of some complications associated with T2D. However, Ramachandram et al., (2013) argues that behavioural modification for T2D are effective but sometimes the programmes are labour intensive and may be difficult for some people.  Therefor the use of mobile phone message is an easier and less expensive means of delivering educational and behavioural modification advice. Moreover, this method has been more effective in high risk men with T2D.

INTERVENTION PLAN

The intervention plan for this project is aimed at improving health and reducing the high prevalence of T2D using Peer Education intervention approach. According to  (NHS,2017) and WHO Global Health Action Plain, 2016) creating more awareness in the community on developing good healthy eating habits, maintaining healthy weight as well as getting more physically active have been effective preventive and management measures for T2D(NHS,2017) and WHO Global Health Action Plain, (2016). Additionally, the use of Peer Education approach has been one of the effective intervention method in meeting the needs of communities, families and young people. It also one of the beneficial strategies used in public health to promote some positive health behaviours such as smoking cessation, violence, substance abuse, and Hiv/Aids prevention especially in young people (Iran, 2013). UNAIDS, (1999) states that Peer education particularly involves the act of individuals from an actual group to impact change among other members of the same group. It is an intervention approach that is culturally sensitive to behaviour modification, life style changes and the use social learning theory and health belief model to promote and improve health.

Based on the research carried out for this project, there is a clear justification to show that peer education intervention approach has been effective in addressing the misconceptions, beliefs, behaviours and life style factors that predisposes South Asians to high prevalence of T2D (Maclntyre, 2011).

This intervention will be tackling the high prevalence of T2D among South Asian adults living in London borough of Croydon by creating more awareness and using a behavioural change approach to reduce the risk of T2D. A health belief model will be adopted which demonstrates healthy behaviour and change by focusing on the individual. This model confirms that people beliefs on the risk of being affected by a disease or health problem and understanding the benefits of changing their own behaviour and life styles influences their willingness to take actions and adapt to these changes. They are also more likely to change their lifestyles when the very aware of the benefits and complications that can result from it. The use of this model is important and will be considered when designing the intervention in other to achieve a more positive result (Green and Murphy, 2014) and (Glanz1 and Bishop,210).

Using the Whitelaw, Bigender and Bryce (2001) description of the five settings for health promotion and putting this into consideration, the setting for this intervention can be described as an active setting since the issue deals with the behaviour of people and the use of available resources within the setting. The intervention will also be cost effective hence the available material resources are rented for free and secondary stakeholders who are the main human resources are from Croydon voluntary service. Also, the location of the venue will be convenient and easy to access for the target group since it is a popular health centre in the community.

The planed intervention will be carried out once in a month for a period of 6months and in the same venue. The main purpose of this intervention is to make the target group more aware of this disease condition, to encourage good dietary habits and promote physical activity through workshop and evidenced based information. Prior to the workshop, information about the workshop will be advertised via distribution of leaflets, flyers, posters and will be available at different services such as Gps, Schools, Library, leisure centres, Community hall, churches, mosque and pharmacies where people can get them easily. The posters, flyers and leaflets will be designed in a colourful way with some pictures showing healthy eating and its benefits in other to attract people easily. It will also contain some brief description of the workshop and direction to the venue. Besides some leaders, from the church, mosque and community will be informed through phone calls to help in informing their members about the workshop. The recruitment process should take about a month (05/06/17) – (5/07/17) and a reminder phone call to the Elders will be made 2 weeks to the event to remind them about the event so they can prompt their members to attend. Furthermore, all the people that responded to the advert or received information from their elders will be welcomed to attend the workshop.

Following this, the intervention will commence on the 10/07/17 and is expected to last for two hours (10am to 12am). Importantly, a brief training will be given to all the professional teams involved in the intervention before the intervention starts. Therefore, they will be arriving an hour earlier to the starting time. The training will enable them to have a clear understanding of the main aim of the intervention, how the intervention will be conducted and how to respond to the effectively to the behaviours and concerns of the participants. Moreover, some leaders from the church, mosque and community within the target group will be recruited as role models during the workshop. Bandura, (1986) states that the use of role model in peer education have been effective in behaviour modification and people can serve as models of human behaviour. Besides some people who are valued by others can elicit behaviour change in certain individual due their position. Furthermore, Glanz, and Bishop, (2003) and Bandura, (1997) agrees that individuals do not learn by just their own experience but they also learn by observing the actions of other people and the results of those actions. They are also more willing to change their ill behaviours or habits by observing and learning their role models behaviours. Hence the use of role model during the workshop can promote healthy eating habits and positive behaviours that can improve health among the participants.

On the workshop day, a questionnaire will be designed which will help in gathering information about the knowledge, beliefs and goals of the participants. Firstly, the dietitian will deliver health education session on how the attendance can prepare healthy meals and eat healthy meals within their budget considering their traditional dietary habits.  For example, the use of common healthy food stocks and vegetables which they can grow local or buy from their local shops will be used to show some samples of healthy foods. This will help them to understand the misconceptions that healthy foods are expensive and takes time to prepare. Also, findings from SAH, (2014) confirms that South Asians consume more foods that are high in sugar, carbohydrates and fats during their religious festive period. Therefore, advice and support on unhealthy eating habits and how they can manage their diets especially during religious rituals and events like Ramadan will be given.

The physical activity session will be delivered by a trained exercise instructor. In this session, information on the importance of being physically active and how to be more active using the available leisure activities in their individual homes or community will be given. Individuals who are keen on losing weight will be supported with individual goal plans.

In addition, the weighing session and NHS health checks which will be carried out by a volunteer community nurse. During this session, individuals who have been found to be at high risk of developing T2D from their weight will be given a one to one session. This will enable them to voice out their concerns, fears, misconception and factors that contributes to their vulnerable to the condition. They will equally be supported to clear their misconception using a none judgemental approach that will empower them to be more aware on how their own life styles, diets, beliefs and behaviour contributes to their vulnerability. On the other hand, it is important to be aware that individual’s personality, culture and religion can impact on these life style changes and behaviour modification thereby bringing limitation to the intervention (Bandura,1998).

At the end of the workshop, all the participants will be will be given leaflets on risk factors of T2D, healthy eating recipes, exercise guide, useful web links and list of available services for T2D within and outside the borough. Individuals that have been identified to be at a high risk will be referred to other services for more support. Kenny et al, (1998) supports the use of information leaflets and effective communication throughout the workshop increase reliability and acceptability of the information.  Thus, people are more likely to accept information and act on it when it is in written form and handed out by health professional who we entrust on our health care and health information. A follow up will be carried out 3 weeks after each workshop to identify some relapse cases, those that still needs more support and to arrange more support for them.

The identified target population for this project can be defined as a symbolic community as they are a group of adults with the same common interest, culture, ethnicity and equally living in the same borough of Croydon (Laverack,2007). In addition to this, Laverack, (2006) recommends that community empowerment can improve community interest and participation. Thus, people from this ethnicity coming together to achieve a common goal will increase community interaction within them and helping them to tackle T2D by sharing knowledge, experience and rising more awareness. Subsequently, judging from the response from the participants, it can be anticipated that this intervention will be effective and will help to reduce the high prevalence this diseases condition in the borough. Furthermore, Laverack (2007), also explains the distribution of power in health promotion using the power-over”.and “power-with”. This shows that the use of power at the beginning of this intervention will be “power-over”. Hence the professional team involved in this intervention will have empowering the participants as well as having knowledge and control of the available resources for the intervention. While the use of power-with will enable the participants to have increased knowledge and awareness on the importance of healthy eating and being physically active.

 

 

 

 

 

Chapter 6

Ethics

The key ethical issues will be considered throughout the period of intervention and implementation. This will help to ensure that every step taken in carrying out the purpose of the intervention is ethically accepted. The ethical application that have been considered for this intervention is in line with the Nuffield Council on Bioethics (2007). Moreover, it is important to design and carryout the intervention in such a way that it is culturally sensitive and acceptable to suit and meet the needs of South Asian adults and their community (Laverack,2007) For instance the culture and religion of south Asian is most times a priority to them and their preferences in regards to this will be respected throughout the intervention period.

Additionally, language barrier has always been an issue when delivering an intervention and health promotion to the community and the public. Consequent to this, a translator will be provided to promote effective communication within the service and support those that needs it. It is also important to ensure that individuals are supported to adopt to their behaviour changes or habits through referral to behaviour change services provided within the community. Confidentiality is also deemed important when delivering an intervention and will be maintained throughout the intervention. Furthermore, use of stewardship model will be adopted to reduce inequalities and in closing the gap between the most and least deprived in this community (…………………)

                                 Stakeholder Analysis.

Varvasovsky, and Brugha, (2000) clearly agrees that the use of stakeholder analysis is very crucial in every intervention as they help to achieve participation, commitment and ownership. Hence it is vital to acknowledge the need of working with different stakeholders and the differences in their roles, knowledge, power, contribution and connections that will enable effective planning, implementation and evaluation of the intervention. An analysis of the stakeholders can be seen on the table below and have been adapted from the WHO stakeholder Analysis Guidelines in other to provide information on the stakeholders involved in this intervention (Schmeer, n.d.).

	Stakeholder		Knowledge	Position	Interest	Alliances	Resources	Power	leadership
Primary	South Asians Adult (30-60).		Low/ Medium	Low influence during the planning and implementation process	This is high as they are the target group and main beneficiaries   of the intervention.	High because they are the     participants and the intervention needs to be acceptable to them.	Low	Low	Low
		Elders in the church, mosque and community	Low/ Medium	Low/ Medium	High They will act as role models to facilitate changes in the behaviour and life styles of participants.	Medium High because they are interested in tackling T2D and to promote    their community health.	Low/Medium They can be a source of human resources for the intervention	Medium They have ability and authority to make changes and decision for their members and the community at large.	Medium They have influential power that can promote positive behaviour and health.
Secondary		Community nurse	High	High: For health checks Advice, weighing	High	Medium	High	High	High
		Dietitian	High	High: will be involved in planning and implementing the intervention	High	Medium	High	Medium/High	Medium/High
		Exercise instructor	High	High: Exercise advice and support. Involve in planning and implementation.	Medium	Medium	Medium	Medium	Medium
Key Stakeholders		Croydon council Department of Public Health	High	High: They interested in tackling the high prevalence of T2D .	High	High	High	High	High
		NHS England	High	High	Low/ Medium	Medium	High	High	High
		Public health England	high	High	Low/ Medium	Medium	High	High	High

	Budget/Resources
What is needed	Amount
Payment for hall(venue)	The venue will be a community town hall will be rented free for community health promotion. So, no payment is required.
Telephone call charges
Cost of leaflet and flyers design
Cost of printing the leaflet and flyers(Colour)
Cost of translating the leaflet
Cost for Printing the questionnaire (black/white)
Translator for the one-to-one session
Community nurse Nutritionist Exercise instructor	All the secondary stakeholders will be recruited from Croydon voluntary services. Therefore, no salary and payment will be required.
Cost of training
Salary for the Public health personnel
Travel expenses
Light healthy snack for stakeholders and participants.

Chapter 7

Conclusion and expected outcome

T2D is generally on the raise globally and is no longer a disease of predominately rich people and developed nations. It is presently worst in worlds middle income countries (WHO,2016). Moreover, the prevalence of T2D in Croydon is associated to the main social determinants health and the increase in migration of people of South Asian descent into the borough (JSNA, 2013-2018). Therefore, the South Asian population in Croydon and UK at wide remains an important target group for the prevention and intervention measures for T2D as they are at high risk of developing this condition even at a younger age than the White Europeans (SAHF,2014).

Nevertheless, many local policies, evidence based practice and interventional interventions have been targeted at reducing the pandemic of this disease yet the prevalence rate remains very high. This suggests that more researches and preventive measures should be put in place to reduce the high prevalence rate, high mortality rate and economic burden. Also, the data and questionnaire collected in this intervention will be used for service improvement within and outside the borough. (Zimmet et al.,2001) and IDF(International Diabetes Federation 7th Edition 2015). The expected outcome for this project is to have an increased awareness of T2D, increased physical activity and improved healthy eating habits. Once more Ethical consideration remains important and will be considered throughout the planning and implementation of this intervention.

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